(A)
The purpose of this rule shall be to
establish standards and criteria, indications, contraindications and limits for
referral of adult ODMH regional psychiatric hospital
(RPH) inpatients to an outside
facility for ECT.

(B)
The
provisions of this rule shall be applicable to all RPHs under the
managing responsibility of the department.

(1)
"Chief clinical officer" and "CCO" mean the medical director of
an RPH as defined in division (K) of section
5122.01 of the Revised
Code.

(2)
"Psychiatrist" means a licensed physician
who has satisfactorily completed a residency training program in psychiatry, as
approved by the residency review committee of the American medical association,
the committee on post-graduate education of the American osteopathic
association, or the American osteopathic board of neurology and psychiatry, or
who on July 1, 1989, has been recognized as a psychiatrist by the Ohio state
medical association or the Ohio osteopathic association on the basis of formal
training and five or more years of medical practice limited to psychiatry.

(3)
"ECT" is a somatic psychiatric treatment mediated by a modified
grand mal seizure, which is induced by the application of electrical current of
the brain.

(4)
"Informed consent" means the voluntary and knowing permission given by a person
who has received all appropriate information.

(3)
The RPH psychiatrist must present clinical data
to the RPH CCO to obtain approval for ECT referrals.

(4)
It is required that any patient,
voluntary or involuntary, competent or incompetent, shall be given a full
explanation of ECT consistent with the specific items cited below:

(a)
An explanation of the procedures to be
followed and their purposes including identification of any procedures which
are experimental. This explanation is to be given in such a way as to enable
the individual to make a decision to grant/deny consent;

(b)
A description of any attendant
discomforts and risks reasonably to be expected;

(d)
A disclosure
of any appropriate alternative procedures/treatments that might be advantageous
for that patient including an explanation of the consequences of those
procedures/treatments;

(e)
An
offer to answer any inquiries concerning the procedures and answers to any such
inquiries;

(f)
An instruction that
the individual may refuse to consent and that the individual is free to
withdraw his consent and to discontinue the treatment at any time without
prejudice unless informed consent for the ECT is given
by guardian or court-ordered; and

(g)
A notification that the individual may
consult with an independent specialist and counsel.

(5)
The competence of a patient to give
informed consent shall be determined by the attending psychiatrist. The written
opinion shall be incorporated into the patient's permanent medical record.

(6)
The criteria for determining
the competence of the patient, include but are not limited to:

(a)
Whether or not the patient is physically
and mentally able to receive the information required to be furnished;

(b)
Whether or not the patient is
able to explain his/her understanding of the information provided; and

(c)
Whether or not the patient
demonstrates that he/she has evaluated the information provided.

(a)
If an adult patient has been adjudicated
incompetent to give informed consent for medical treatment by a probate court,
the patient's guardian may give informed consent.

(b)
If an adult patient has been determined
to be incompetent to give consent according to the procedure outlined above,
and has no guardian, ECT may be administered only under the following
conditions:

(i)
The attending psychiatrist
must certify in writing that an indication for ECT use as outlined in paragraph
(E) of this rule is evident;

(ii)
The chief clinical officer recommends in writing the administration of ECT; and

(iii)
If a durable power of
attorney for healthcare issues exist, it should be followed. Otherwise,
approval for ECT shall be obtained from the probate court.

Referrals for ECT are based upon a combination of factors,
including the patient's diagnosis, nature and severity of symptomatology,
treatment history, consideration of anticipated risks and benefits of viable
treatment options, and patient preference. At present there are no diagnoses
which should automatically lead to treatment with ECT. In most cases, ECT is
used following treatment failure on psychotropic agents, although specific
criteria do exist for use of ECT as a first-line treatment.

(2)
Primary use of ECT Situations where ECT
may be used prior to a trial of psychotropic agents include, but are not
limited to, the following:

(a)
Where a need
for rapid, definitive response exists on either medical or psychiatric grounds;
or

ECT may be an effective treatment for
psychotic schizophrenic exacerbations including catatonia, when prominent
affective symptoms are present and when there is a history of favorable
response. ECT may be effective in other psychotic disorders.

(d)
Mental disorders
due to a general medical condition. ECT may be effective in the management of
severe affective and psychotic symptoms concomitant with general medical
conditions, or in treating delirium of various etiologies, including toxic and
metabolic.

(i)
For people with
diagnoses for which efficacy data for ECT are only suggestive, or where only a
partial consensus exists in the field, support its use. In such cases, ECT
should be recommended only after standard alternatives have been considered as
a primary intervention. The existence of such indications, however, should not
deter the use of ECT for treatment of a concurrent major diagnostic
medication.

(ii)
Although ECT has sometimes been of assistance in the
management of mental disorders other than those described above, such usage i
snot adequately substantiated and should be carefully justified in the clinical
record on a case-by-case basis.

(a)
Situations exist in which ECT is
associated with an appreciable likelihood of serious morbidity or mortality. In
such cases, the decision for ECT should be based upon the premise that the
patient's condition is too grave, (i.e., life threatening) to leave untreated,
and that ECT is the safest treatment available.

(b)
In these instances, careful medical
evaluation of risk factors should be carried out prior to ECT, with specific
attention to treatment modifications which may diminish the level of risk.

(2)
The
psychiatrist who is responsible for the administration of ECT has been
credentialed and privileged in ECT by the facility where the ECT is being administered.

(I)
Training When ODMH
RPH
patients are receiving ECT as outpatients, the RPHnursing
staff shall be provided with appropriate training on nursing care for these
patients to assure competent care of pre- and post-ECT
treatment.

(J)
Reference "Recommendations for Treatment, Training,
and Privileging: A Task Force Report of the American Psychiatric Association,
2nd ed., 2001".